Primary Trauma Care in Lao PDR: Recent Developments and Training Programs

1. PTC: Primary Trauma Care Dr. ThepbandithSydavong Emergency Medicine Resident Year 2

2. Trauma in Lao PDR

4. Trauma in Lao PDR

5. WHO GLOBAL STATUS REPORT ON ROAD SAFETY 2015: LAOS

6. The Central Hospitals

7. Mahosot Hospital Road Traffic Accidents:2012: 8.6% of ER patients2013: 6.9% of ER patients2014: 5.6% of ER patients

8. Setthathirath Hospital • 2017 Patients seen in ER: 25050 • 2017 Road Traffic Accident: 2568 Road Traffic Accidents made up 10.3% of ER patients in 2017.

9. Mitthaphab Hospital • The designated trauma center • Neurosurgery capability • Future: • New hospital: 300 beds + 250 beds • EMS Dispatch Center under central number

10. Recent and Future Developments

11. Recent and Future Developments

12. The Future of PTC • Support MOH and UHS to have all healthcare providers certified in PTC. • 2-1-2 training of 34 provincial doctors and nurses by November 9th 2018 • Train all EM residents as PTC trainers. • November 2019: PTC trainings in 14 provinces

13. PTC Primary Trauma Care Foundation Primary TraumaCare 1

14. What is PTC? Primary Trauma Care is a 2 day course training health professionals in acute management of the severely injured patient. 2

15. PTC 2-1-2 day • 2 day PTC Course • 1 day Instructor training day • Newly trained PTC instructors immediately teach a second 2 day course.

16. PTC Instructors

18. PTC Mission Statement • A system of training for front-line staff in trauma management • Aimed at preventing death and disability in seriously injured patients • Using available resources • To train clinicians to teach PTC principles in their hospitals 3

19. PTC 2 day course • At the end you will • understand and apply a system for assessing and treating trauma patients • have the knowledge, skills and attitudes of the PTC principles • apply these PTC principles to where you work 4

20. PTC emphasises basic trauma care with the available resources When do trauma patients die? What are the common disabilities? What resources are available? 5

21. When do trauma patients die? • Seconds - minutes (50% deaths) • Brain and spinal cord, heart, great vessels • 1-2 hours (35% deaths) • Head injury, chest, abdomen, fractures causing large blood loss • Days to weeks (15% deaths) • Sepsis, organ failure 6

22. PTC System • Prevention • Triage • Primary survey • Secondary survey • Stabilisation • Transfer • Definitive care 7

23. PTC System • Triage • Sorting patients according to priority • Priority depends on • experience • resources • severity of injury 8

24. PTC System • Primary Survey (ABCDE) • rapid examination • life-threatening injuries • treat as you find • Secondary Survey • history • detailed head to toe examination • all injuries • special Investigations if available 9

25. PTC System • Stabilisationincludes • re-assessment • optimisation • documentation • communication • when stable • Transfer for definitive care 10

26. Primary Survey • Systematic examination to detect life threatening injuries • Rapid - 5 minutes • Treat as you find • Repeat if unstable • Universal precautions 14

27. Primary Survey • Airway + Cervical spine control • Breathing • Circulation • Disability • Exposure 15

28. A Airway and Cervical spine 16

29. AirwayAssessment • Can the patient talk? • Look, feel, listen • colour, conscious state • accessory muscle use • sounds 17

30. AirwayBeware • Airway obstruction • Breathing difficulties with chest injuries • Cervical spine injury 18

31. AirwayManagement • Clear mouth • Basic airway • Advanced airway • Cervical spine protection 19

32. B Breathing 20

33. BreathingAssessment • Is the breathing normal? • Are there chest injuries? • Look, feel and listen 21

34. BreathingAssessment • Air / Chest movement • Respiratory rate • Tracheal deviation • Accessory muscle use • Percussion / Auscultation 22

35. BreathingBeware • Life threatening injuries • Airway injury • Tension pneumothorax • Open pneumothorax • Massive haemothorax • Flail chest • Lung contusion 23

36. BreathingManagement • Give oxygen • Assist ventilation • Decompress pneumothorax • Drain haemothorax 24

37. C Circulation 25

38. CirculationAssessment • Is the patient in shock? • Is there bleeding? • Look, feel and listen 26

39. CirculationAssessment • External bleeding • Signs of shock • fast pulse • poor capillary return • low blood pressure 27

40. CirculationBeware • Life threatening haemorrhage may be hidden • chest • abdomen • pelvis • long bone • external before arrival 28

41. CirculationManagement • Stop bleeding • 2 large bore intravenous cannulae • Take blood for crossmatch and base line investigations • Give i/v fluid • Monitor urinary output. 29

42. D Disability 30

43. Disability • AVPU • Is the patient Awake? • Is the patient responding to: • Voice? • Pain? • Is the patient Unresponsive? • Pupils? 31

44. E Exposure (& Temperature Control) 32

45. Exposure • Are there any hidden injuries under clothing? • Keep patient warm 33

46. Primary Survey • Monitoring • Investigations • X rays • Procedures • Pain relief – preferably i/v 34

47. Reassessment of ABCDE If patient is, or becomes, unstable 35

48. Sources • Lao PDR Health Systems Review 2014, WHO Asia Pacific Observatory on Health Systems and Policies: http://www.searo.who.int/entity/asia_pacific_observatory/publications/hits/hit_lao_pdr/en/ • Data Collection Survey on Health Sector in Lao People’s Democratic Republic, JICA March 2016: http://open_jicareport.jica.go.jp/pdf/12252698_01.pdf • Health Service Delivery Profile Lao PDR 2012, WHO and MOH: http://www.wpro.who.int/health_services/service_delivery_profile_laopdr.pdf • Human Development Report 2016 Lao PDR, UNDP: http://www.la.undp.org/content/lao_pdr/en/home/library/human_development/global-human-development-report-2016.html • Global Status Report on Road Safety 2015, WHO: http://www.who.int/violence_injury_prevention/road_safety_status/2015/en/ • Global Burden of Disease Study 2010 Country Report Laos: http://www.healthdata.org/sites/default/files/files/country_profiles/GBD/ihme_gbd_country_report_laos.pdf • Lao Statistics Bureau: https://www.lsb.gov.la/lo/%E0%BA%AD%E0%BA%B8%E0%BA%9B%E0%BA%B0%E0%BA%95%E0%BA%B4%E0%BB%80%E0%BA%AB%E0%BA%94/#.WnVxA6iWZPb • https://www.uxolao.org/ • http://www.worldlifeexpectancy.com/country-health-profile/laos • 50 Years Working for Health in Lao PDR, WHO 2012: http://www.wpro.who.int/publications/lao_50years_bh_correct_030513b.pdf • Census Lao PDR 2015: http://lao.unfpa.org/publications/results-population-and-housing-census-2015-english-version • Emergency Department Mahosot Hospital Presentation by Dr. BouasoneBounta for the Annual Meeting of the LSA December 2016